COVID Vaccine Business Inquiry Form
Nevada County Public Health wants to make vaccine accessible to all. Part of that effort is to bring vaccine to you. If your business would like to request a COVID vaccine event at your location, or at a Public Health location, please complete the form below.

After you fill out this form, your information will be reviewed and you will be contacted by our outreach team to make further arrangements. Depending on demand, certain types of business may be prioritized for on-site vaccination. We will do our best to serve everyone interested in vaccination.

For general COVID questions, contact 211 by dialing 2-1-1 or 1-833-DIAL211. You can speak with a local call agent 24/7 in English or Spanish.
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Business name *
Primary contact's name (first and last) *
Primary contact's email address *
Primary contact's phone number *
Business location(s)
What best describes your business/organization?
If you selected "Other," please briefly describe your business/organization
Total number of staff *
Number of staff you anticipate would like to be vaccinated on-site *
What percentage of those staff speak Spanish as a first language?
Would any of your staff require accommodations (for instance, to accommodate a disability)? If so, what kind of accommodations?
Any additional information you'd like to share?
Submit
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